Chapter 6 SOCIAL SECURITY TITLE II BENEFITS

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1 Chapter 6 SOCIAL SECURITY TITLE II BENEFITS Benefits Planning, Assistance and Outreach Introduction The benefit program authorized under Title II of the Social Security Act enables individuals who have become disabled and are unable to work to receive monthly cash benefits and Medicare insurance. As explained in the first section, to qualify for Social Security benefits, individuals must be determined medically disabled, and must not be working or, if working, earning less than the level. They must also have insured status (i.e., sufficient past work in Social Security covered employment) or are individuals who are 18 or older, who have become totally and permanently disabled before age 22, and who are dependents of insured workers who are disabled, retired or deceased, or be the disabled widow or widower (50 years of age or older) of a deceased spouse. The Social Security program is not based on economic need; therefore there are no restrictions on unearned income limitations to be entitled to it as there are for SSI. The dollar amount of income support received by Social Security beneficiaries on a monthly basis is dependent on the level of contributions made to the program, which varies significantly from person to person. There are no provisions for gradual reductions in Social Security cash benefits as earnings increase, as is the case with the SSI program. Social Security beneficiaries will either receive the full amount of their Social Security benefit per month or receive no income support at all. Please refer to Flowchart #1 on page 67 for a visual guide to Social Security. Trial Work Period (TWP) Unless medical recovery is an issue, individuals receiving Social Security based on disability are entitled to a nine-month TWP, which provides opportunities to test work skills while maintaining full benefit checks regardless of any income earned. The TWP is a work incentive and begins the first month that individuals are entitled to Title II benefits or file applications for disability benefits (whichever is later). Effective January 2004, only months during which an individual earns over $580 or works over 80 hours in self-employment are service months and count as TWP months. In 2003 $570, in 2002 $560, and in 2001 $530 per month counted as a TWP month. Prior to January 2001, months in which individual earned over $200 a month or worked more than 40 hours in self-employment counted as a TWP month. The TWP ends only if individuals have performed nine months (not necessarily consecutive) of trial work within a rolling period of 60 consecutive months. TWP months must be carefully tracked; as the 36-month extended period of eligibility (EPE) begins immediately after the nine-month TWP. For Title II beneficiaries, SSA counts the gross monthly income earned in the calendar month, rather than what was received, based on pay dates. Individuals are entitled to a TWP for each period of disability. Subsidy and IRWEs are not considered during the TWP. With the most recent rule changes annual increases to the amount of earnings that can count as a TWP, are linked to the national average wage index Can be reproduced with permission. 49

2 Chapter 6 Benefits Planning, Assistance and Outreach Substantial Gainful Activity () Determination Impact of Work Incentives on Determination Unsuccessful Work Attempt When individuals have accumulated nine months of trial work, a continuing disability review (work CDR) is conducted by SSA. The purpose of the review is to determine whether or not the work is. Unlike the SSI program, work activity remains a major factor in considering whether disability under the law continues. A decision of implies that individuals are performing significant mental or physical duties for profit, and are, therefore, demonstrating the ability to work in spite of their disabling impairment. This determination is made by the claims representatives or ESR and is based on the average monthly income. If individuals are determined to be engaging in, they "cease" eligibility for cash benefits they will receive full benefit checks for an additional three months (the first month of after the end of TWP (cessation month) and the two following months), and then the cash benefits will stop. This 3- month period is called the "grace period" and may occur at any time after the end of TWP. If individuals are determined not to be engaging in, they will continue to receive full benefit checks. There are work incentives available to individuals who receive Social Security that will allow them to continue receiving cash benefits while they test their ability to work and sustain work. The work incentives are to assist the individual in becoming more self-sufficient as they pursue an employment goal. With averaging, the Claims Representative may average the earnings of a period of work that may have a peak or two above the Substantial Gainful Activity guideline. If the average is below the guideline, then the person isn't performing, even if some part of that time their gross earnings were over the guideline. In order to average, the period of work must be fairly consistent, thus large fluctuation in earnings, may not be averaged together. If a person has zero earnings in a month, that zero month will not go into the average. The work can only be averaged during a period when the same level applies. Thus, after 2000, earnings may not be averaged over more than one year. To arrive at the countable earnings used to determine if work is, the dollar amount of IRWEs, special conditions, unincurred business expenses, and subsidies, which have been approved by SSA, are subtracted from the gross monthly earnings. Once the dollar amount of the IRWEs and subsidies are excluded, if countable earnings are below the level, individuals will be eligible for Social Security cash benefits. (The definition and criteria for using subsidies and IRWEs are provided in Chapters 7 and 8.) While the PASS work incentive does not apply to Social Security, many expenses that are paid for under a PASS also meet criteria for exclusion as an IRWE. These expenses can be counted as a PASS for SSI payment calculation purposes and simultaneously be calculated as an IRWE in the determination for Social Security. The final tool is an Unsuccessful Work Attempt. Work for less than three months that exceeds the guideline, and ends because of the person's disability may not demonstrate that ability to perform. If the SSA considers this work to be a Unsuccessful Work Attempt, the person s benefits are not ceased Can be reproduced with permission.

3 Benefits Planning, Assistance and Outreach Chapter 6 If the period of work is between three and six months, it may also represent an unsuccessful attempt to work. In between three and six months, it may also represent an unsuccessful attempt to work. In these situations, however, the person's work must have another factor involved, such as frequent absences, or the removal of special circumstances. Once the person s benefits have been ceased, an Unsuccessful Work Attempt is no longer in the CR s toolbox. An unsuccessful work attempt is an effort on the part of a beneficiary to do substantial work (in employment or self-employment) which they stopped or reduced to below the level after six months or less because of one of the following criteria: their disability/impairment; or removal of special conditions related to their impairment upon which further performance work is required. SSA will not count earnings during an unsuccessful work attempt when they make an decision for initial SSI or SSDI eligibility, or when they decide if disability continues or ceases because of work under the SSDI program. Determination Process In making determinations, the SSA claims representatives or ESR will contact Title II beneficiaries. In some cases, the review will be handled by mail or telephone, but in most cases it will be conducted in the local SSA office. The claims representatives or ESRs need information from the individual's employer and/or may refer the case for a medical determination to determine whether the individual continues to have a disabling condition. The claims representative will request information from the individual and their employer regarding extra support and supervision supplied, and special accommodations and arrangements made, to enable individuals to obtain and maintain employment. This form is called the Work Activity Report and is available online or available at the local social security office. Communication should occur, with all parties submitting information to ensure accurate presentation of employment situations. Claims representatives and Employment Support Representatives handle scheduling of most work CDRs. Files for Social Security beneficiaries under SS are maintained at the Office of Disability Operations (ODO) in Baltimore, Maryland. NOTE: Some work CDRs are handled in ODO or PSCs. When a nine-month TWP concludes, ODO will forward files to the local SSA office. The case representatives must have the files in order to conduct the review. If the nine months of accumulated TWP have not been consistently reported, there will probably be a delay in conducting the CDRs, as SSA will be unaware that the TWP is ending. Implications of such a delay are as follows: 2004 Can be reproduced with permission. 51

4 Chapter 6 Benefits Planning, Assistance and Outreach For individuals receiving only Social Security who are performing, a delayed CDR may mean that their cash benefits are not terminated promptly, resulting in an overpayment. NOTE: SSA operates on a nofault basis; even though an overpayment may be caused by them, the overpayment is still due to be repaid. NOTE: SSA notified beneficiaries of overpayments, but beneficiaries have a right to request waiver of overpayments due to no fault and inability to repay. Overpayment also occurs as a result of unreported earnings in some cases. For individuals receiving Social Security and SSI who are performing, a delayed CDR may mean that their Social Security is not terminated promptly, resulting in overpayment. Also, a delay in adjusting the dollar amount of SSI upward will occur due to the decrease in unearned income in the form of the ceased Social Security benefit. TWWIIA CDR Protections Effective January 1, 2001, the SSA will not be able to initiate a Continuing Disability Medical Review while an SSI recipient or SSDI beneficiary is using a Ticket under the Ticket to Work and Self-Sufficiency program. This protection is discussed in greater detail in Chapter 21. Extending CDR protections further, effective January 1, 2002, work activity by an SSDI beneficiary who has received SSDI for at least 24 months cannot be used as a basis for conducting a medical CDR. However, as in the prior protection, earning at or above the level may make the individual s benefits subject to termination. However, work CDRs will still be conducted. Also, any previously scheduled medical CDRs will still be conducted unless the beneficiary is exempt due to participation in the ticket program. Extended Period of Eligibility (EPE) At the conclusion of the nine-month TWP, as long as individuals continue to have their original disabling condition, a 36-month EPE will begin in the month following the ninth TWP month. During these 36 consecutive months, individuals will receive benefit checks when their earnings are below (see Flowchart 2 on page 68). During the EPE, individuals are due payment (disability benefits) for any month they do not work, or when work and earnings fall below the level. During this period, it is not necessary to file a new application for benefits to resume. Social Security cash benefits are paid during the EPE only for the months in which countable earnings are below the level. For individuals who are self-employed, individual determinations of what quantifies during EPE will be established. The claims representatives or ESR will make this individualized determination by considering: how many hours of work were performed; who performed the services; net and gross earnings; subsidies; and other particulars Can be reproduced with permission.

5 Benefits Planning, Assistance and Outreach Chapter 6 Consistency and accuracy in reporting to SSA monthly fluctuations in earnings between and non- levels is critical in avoiding overpayment or underpayment of Social Security benefits. When the 36-month EPE ends, if the beneficiary is engaged in, benefits are terminated and the case file is closed. This could occur immediately following the EPE or at any point thereafter, depending on when occurs. Expedited Reinstatement of Benefits (excerpted from The Benefits Planner, Cornell University, Fall 2001) Under pre-2001 law, a person who performed after the EPE would lose SSDI benefits. If the person later lost his or her job or had wages reduced below the level, he or she would have to reapply to re-establish Title II eligibility. This prospect of a new application, with the uncertainty of whether a new decision maker would find the individual disabled (especially in light of recent work activity), made many individuals pause at the notion of taking a chance at work that might not be successful in the long term. The new expedited reinstatement (EXR) program should make more beneficiaries willing to try working, despite a severe disability, knowing they may re-establish eligibility if their work is not sustained because of their impairment(s). NOTE: Under EXR criteria, individuals must have become unable to continue performing because of their impairment(s) and must be under a disability based on the application of the medical improvement review standard (MIRS). The EXR Criteria Effective January 2001, a person who performs after the EPE and had his or her benefits terminated and later has wages reduced below levels because of his or her impairment(s) or health condition will be reinstated to Title II, without a new application, if the individual: was eligible for Title II benefits; lost benefits due to performance of ; requests reinstatement within 60 months of the last month of entitlement (the earliest that someone could have had benefits terminated and be eligible for reinstatement is February 1996), or, if the request is filed after 60 months, the individual establishes good cause for missing the 60- month deadline; has a disability that is the same as (or related to) the physical or mental disability that was the basis for their original claim; and that disability renders the individual incapable of based on application of the medical improvement standard. If an individual believes he or she meets the EXR criteria, the individual should contact SSA and say that he or she wants to request reinstatement. This includes individuals who, in the last five years (since February 1996), stopped receiving benefits due to and who, since their last month of Title II entitlement, also stopped performing because of their impairment(s) or health condition... SSA has issued Field Instructions, outlining the criteria and procedures to be followed by local offices. The instructions also include an EXR request form Can be reproduced with permission. 53

6 Chapter 6 Benefits Planning, Assistance and Outreach If the beneficiary satisfies the EXR criteria, both his or her benefits and the benefits of dependents can be reinstated. Title II dependent s benefits, including benefits for dependent children and spouses, can be reinstated if the dependent satisfies all the eligibility criteria as a dependent (this includes having a new medical determination if the dependent's entitlement is based on being disabled.) A previously entitled dependent does not have to file a new application to qualify for reinstated benefits. New dependents will have to file an application to qualify for reinstated benefits. Provisional Benefits Pending Reinstatement Decision While the EXR request is pending, the individual is eligible for up to six consecutive months of provisional benefits. Provisional benefits are payable when EXR is requested. The individual may also be eligible for Medicare coverage while receiving provisional benefits, if not already covered for such benefits. Provisional benefits may be suspended under current rules (e.g., prisoner suspension), and performing will terminate provisional benefits. Early reports are that SSA is processing these requests quickly and individuals have received provisional benefits within weeks of the EXR request. What happens if SSA later determines that the individual was not entitled to reinstatement? Must they repay the provisional benefits received? SSA s Field Instructions state that any resulting overpayment cannot be recovered unless SSA determines that the individual knew or should have known that he or she did not meet the EXR criteria. A New Trial Work Period and Extended Period of Eligibility For years, Title II beneficiaries were told they would get one TWP and one EPE. The TWP and EPE could be exhausted for good at very low levels of earnings. In fact, the EPE could be exhausted whether the person was working or not. This has changed under the new EXR program. After being paid 24 months (need not be consecutive) of reinstated benefits (including any months for which provisional and retroactive payments were actually received), the beneficiary gets: a new TWP; a new EPE; and another 60- month period in which to request EXR if benefits are terminated again due to. As demonstrated in John s case, the chance for a new TWP and EPE, fortunately, allows the person to work through the peaks and valleys of their continuing disability Can be reproduced with permission.

7 Benefits Planning, Assistance and Outreach Chapter 6 Application of the New TWP and EPE John s case: John was awarded SSDI benefits in 1990 based on a back injury. His monthly SSDI check was $600 in 1990 and higher in 2001 based on cost of living adjustments. In 1993, John goes to work part-time doing lighter work. He earns $400 per month between January and June 1993 when he re-injures his back and stops working. He does not work again until He starts work in October 1998 and works the remainder of 1998 through December 1999 earning $650 per month. In 2000, he gets a raise and earns $720 per month throughout all of 2000 and for the first four months of In late April 2001, John is laid off and earns no money between May and October In November 2001, he goes back to work and earns $1,000 per month between November 2001 and December On New Year s Day of 2003, John aggravates his injured back taking down holiday decorations. He must stop working and remains out of work for the entire year, January to December In January 2004, John returns to work on a lighter schedule. He has gross monthly earnings of $500 between January and December In January 2005, he increases his hours of work and has gross monthly earnings of $1,000 between January and December John worked his first TWP month in January This is the first month he worked as an SSDI beneficiary and earned more than the TWP services month amount ($200 in 1993). Between January and June 1993, he used up six TWP months. When John went to work in October 1998, he had no TWP months within the last 60 months (i.e., between November 1993 and October 1998). This means his TWP started over. Since he then earns at least $200 in gross wages for nine consecutive months, October 1998 to June 1999, John completes his TWP in June NOTE: Under pre-2001 rules, this would be John's only TWP. He would only get a second TWP if he lost SSDI, reapplied, and was awarded benefits on the new claim and had a new five-month waiting period. Effective 2001, the new expedited reinstatement provisions, discussed later in the article, allow John to qualify for a new TWP after he has received reinstated benefits for 24 months. John s EPE began in July 1999 (i.e., immediately following his ninth TWP month). His 36-month EPE will run from July 1999 though June John is clearly eligible for SSDI between July 1999 and December His gross wages of $650 per month were less than the amount in effect at that time and his eligibility continued. (Remember: The monthly level increased from $500 to $700 effective July 1999 and remained at that level through the end of 2000.) January 2000, when John gets a raise up to $720 per month, will be considered his benefit cessation month. This is the first month of during his EPE. (Again, the amount of $700, effective July 1999, continued throughout 2000.) John is entitled to SSDI benefits for January, February and March 2000 the benefit cessation month and two more months. This is his three-month grace 2004 Can be reproduced with permission. 55

8 Chapter 6 Benefits Planning, Assistance and Outreach period. Starting in April 2000, John will get checks only when his countable wages are below the amount. Since his gross earnings were $720 per month throughout the remainder of more than the 2000 amount of $700 he will not receive an SSDI check during the April through December 2000 period. Starting in January 2001, John will start getting SSDI checks again. This is because the amount was increased to $740 and John's monthly earnings remained at $720. He will get SSDI checks for January through April as his earnings remained below $740. He will also get checks for the months of May through October 2001 when he was out of work and earned nothing. Starting in November 2001, John earned $1,000, which is more than the amount. This means he will not get checks for November or December Since his wages remained over throughout 2002, John will continue to be ineligible for SSDI through the end of his EPE (i.e., through June 2002). Since John stopped working for health reasons, he became eligible for EXR in January 2003, because his wages were now below the amount, it was within 60 months of his last month of entitlement to SSDI (i.e., within 60 months of October 2001), and the other EXR criteria are met (i.e., has the same or related impairment and is disabled based on the application of the MIRS criteria). We assume that John would have applied for EXR as early as January 2001, or as soon as it became apparent that he would not return to work right away. We expect that John would be eligible for up to six months of provisional benefits while his EXR request was being processed. (NOTE: One can argue that the 60-month time limit for EXR applications begins after the last month of the EPE rather than after the last month John received an SSDI check. This issue should be clarified when SSA issues EXR instructions in its Program Operations Manual System or POMS.) The facts indicate that John had no earnings during 2003 and his wages during 2004 were $500 per month, well below the level. In addition, having been found to meet the EXR medical criteria, John is eligible for EXR benefits for all of 2003 and 2004, a 24-month period. A new TWP and EPE: When John returns to work in January 2005 he will be entitled to a new TWP. This is because John received reinstated benefits for at least 24 months. Since he made at least the TWP amount each month, his new TWP would run from January through September His new EPE would start in October 2005 and run for 36 months through September The same EPE rules would apply as did in the earlier years. Medicare Coverage Medicare provides medical insurance coverage to Social Security beneficiaries. Individuals with disabilities must complete a five-month waiting period from the month of disability onset before Social Security benefits begin. An additional 24-month waiting period (Medicare Qualifying Period) after disability cash benefits begin is required before individuals are entitled to Can be reproduced with permission.

9 Benefits Planning, Assistance and Outreach Chapter 6 receive Medicare coverage. It is not required that the 24 months be accumulated consecutively. Individuals may accumulate 12 months of the 24-month period before losing Social Security entitlement due to earnings over. If individuals re-establish entitlement for Social Security at a later date, they will need to complete only the final 12 months of the 24-month waiting period before Medicare coverage begins. In addition, if Social Security beneficiaries complete the 24-month period prior to losing Social Security and become entitled again for Social Security within five years (or seven years for childhood disability beneficiaries), a new 24- month period is not required. If entitlement for Social Security disability benefits is re-established after five years, but is based on the same or directly related disabling impairment, a new 24-month Medicare waiting period is not required. Two Part Medicare Medicare has two parts: hospital insurance and medical insurance. Hospital Insurance (Part A) Hospital insurance, like the Social Security program, is financed through part of the FICA payroll tax and helps pay for inpatient hospital care and certain follow-up care. This part of the Medicare program is automatic for Social Security beneficiaries upon completion of the 24-month waiting period. Medical Insurance (Part B) Medical insurance helps pay for doctor s services and a variety of other medical services and supplies that are not covered by hospital insurance. Unlike hospital insurance, medical insurance is voluntary and is financed in part by the monthly premiums of individuals who enroll. Enrollment occurs automatically for those receiving Social Security at the time when hospital insurance entitlement begins. Those choosing to buy medical insurance coverage will have their monthly premiums deducted from their monthly Social Security cash benefits. If beneficiaries Social Security cash benefits are suspended for some reason (i.e. month in the 36-month EPE period), they are billed on a quarterly basis for the Part B premium 2004 Can be reproduced with permission. 57

10 Chapter 6 Benefits Planning, Assistance and Outreach Medicare Premiums Individuals who are disabled and working who have lost eligibility for premium free HI due to may enroll in Medicare Part A (hospital insurance) by paying a monthly premium. Individuals who elect to purchase the hospital insurance (Part A), may enroll in Medicare Part B (medical insurance). The 2004 monthly premium for Medicare Part B is $66.60 per month. NOTE: The amount received each month is the net amount; the gross Social Security benefit is this amount plus the Part B premium.) Part A Hospital Insurance Monthly Premium Part B Medical Insurance Monthly Premium Original Medicare Plan Deductible and Coinsurance Amounts $0 if individual or spouse has 40 or more quarters of Medicare covered employment $66.60 Part A Hospital Insurance Part B Medical Insurance $343 paid only by individuals who are not otherwise eligible for premium free hospital insurance and have less that 30 quarter of Medicare covered employment Deductible $876 per benefit period Coinsurance: $219 per day for the 61 st 90 th day each benefit period Deductible: $100 per year (You pay 20% of the Medicare approved amount for services after you meet the $100 deductible) $438 per day for 91 st 150 th day for each lifetime reserve day $189 for those having quarters of Medicare covered employment Skilled nursing (coinsurance) $ per day for the th day each benefit period Excerpted from: Can be reproduced with permission.

11 Benefits Planning, Assistance and Outreach Chapter 6 Extended Medicare Coverage Pre-TWWIIA Extended Medicare Coverage Under TWWIIA Social Security beneficiaries who lose benefit entitlement due to performance of, but continue to be disabled, are eligible for extended Medicare coverage. The extended coverage is for a minimum of 39 months following the conclusion of the nine-month TWP. The 39-month period is derived from adding the original 15-month EPE reinstatement period (pre-1987) to the 24- month pre-twwiia extended Medicare coverage. Beneficiaries who are still in their Medicare 24-month qualifying period could have less than 39 months if they returned to work shortly after their month of entitlement. This is more the exception than the rule. Section 202 of TWWIIA further extends Medicare coverage for most Title II beneficiaries who work. Beneficiaries will get an additional 4 ½ years coverage beyond the current limit (for a total of 8 ½ years including the TWP). This incentive became effective October 1, Under this provision, insurance can generally continue for 78 months with the first month of occurring after the 15 th of the month of the EPE. This is why under TWWIIA, Medicare coverage extends for at least 93 months (15 months of EPE and 24 months pre- TWWIIA extension and 4 ½ years TWWIIA extension). Specifically, where Title II benefits end because of following a TWP, Medicare coverage ends based on one of the following: 1. If the first month of following the end of the TWP occurs prior to the 14 th month of the EPE and the individual performed in the 16 th month of the EPE, D-HI extends for 78 months after the 15-month EPE. D-HI ends the last day of the 57 th month following the end of the 36-month EPE. 2. If the first month of following the end of TWP occurs prior to the 14 th month of the EPE and the individual does not engage in in the 16 th month of the EPE, D-HI ends with the last day of the 77 th month following the first month of occurring after the 16 th month, and terminates on the first day of the 78 th month. 3. If the first month of following the end of the TWP occurs after the 13 th month of the EPE, D-HI ends with the last day of the 80 th month following the first month of occurring after the TWP, and terminates on the first day of the 81 st month Can be reproduced with permission. 59

12 Chapter 6 Benefits Planning, Assistance and Outreach Beneficiaries will be eligible for the extension under TWWIIA if they: are starting to work for the first time since their entitlement; or are in a TWP; or are in an EPE that began after June 1997; or are in an EPE that began prior to June 1997 and still has premium-free coverage that was not due to terminate until after 9/30/2000, and fraud or similar fault is not an issue Can be reproduced with permission.

13 Benefits Planning, Assistance and Outreach Chapter 6 TWWIIA Extended Medicare Coverage Decision Tree Did occur prior to the 14 th month of EPE after the TWP? NO Did occur after the 13 th month of the EPE? YES YES Did the individual perform in the 16 th month? YES NO Did occur after the 16 th month of the EPE? Start counting 80 months beginning with the month following the first month of after the 13 th month of the EPE to determine when the person s Medicare ends. Begin counting 57 months off starting the month following completion of the EPE to determine when the person s Medicare ends. or if later YES Start counting 77 months beginning with the month following the first month of after the 16 th month to determine when the person s Medicare ends. or if later The date of the benefit termination notice plus one month The date of the benefit termination notice plus one month NOTE: In all three cases, Medicare would end the last day of the month as specified above and terminate the first of the following month Can be reproduced with permission. 61

14 Chapter 6 Benefits Planning, Assistance and Outreach Examples/Exercises #1: Application of Rule #1 You just received a call from an individual who tells you that their TWP ended in 12/98. They reported working at every month since their TWP ended and don t anticipate working at a lesser level. They want to know at what point their Medicare coverage will end. Begin by recording all the relevant and pertinent information below making sure to record the TWP ending date, beginning of EPE and months in which the individual worked at. The example is illustrated below. Year Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 1998 TWP Ended EPE Starts Benefits End EPE Ends/ Med Ends Can be reproduced with permission.

15 Benefits Planning, Assistance and Outreach Chapter 6 You will note that the individual s TWP ended 12/98, putting the start date for their EPE in 1/99. They have earned every month since 12/98 and if were to continue the EPE would be expected to end 12/01, with cash benefits terminating on 1/1/02. (Benefit cessation cannot be earlier than the last day of the month with benefit termination occurring the first day of the next month.) Given that benefit termination would not occur until after 9/30/00, the TWWIIA provisions apply. Given that the individual earned prior to the 14 th month of the EPE and again in the 16 th month, the first rule applies. The 15 th month of the EPE is 3/00 and you should begin counting 78 months into the future to identify that this individual s Medicare coverage would cease on 9/30/06 with a termination on 10/1/06. #2: Application of Rule #2 If in Example #1 the individual did not earn at or above the level in the 16 th month of the EPE but did in the 18 th month (6/00), the 77 count down would begin in 7/00 with benefits ceasing on 12/11/06 and terminating 1/1/07. The table below outlines this calculation. Year Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 1998 End TWP EPE Begins No 5 17 No Medicare Ends 78 Medicare Terminates 2004 Can be reproduced with permission. 63

16 Chapter 6 Benefits Planning, Assistance and Outreach #3: Application of Rule #3 If the individual had not earned prior to the 13 th month of their EPE, but earned the 18 th month, the individual s Medicare would continue until the last day of the 80 th month following that first month of. The table below details this rule. Year Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec 1998 End TWP EPE Begins Non Medicare Ends 81 Medicare Terminates Final Comments Be careful when assisting individuals in determining Medicare cessation/ termination. These rules are complex and the practitioner should always confirm their findings with SSA. Keep in mind; if the beneficiary s situation under the pre-twwiia policy results in termination of coverage prior to 9/30/00, the beneficiary would not get extended coverage. Also keep in mind use of IRWE or subsidy could result in an individual s earnings being lower than, which might assist individuals who miss qualifying for TWWIIA extended coverage as a result of the ending of their EPE due to performance of in the 36 th month (refer to the section on EPE on page 52) Can be reproduced with permission.

17 Benefits Planning, Assistance and Outreach Chapter 6 Medicare Buy-Back Option It is possible for individuals with disabilities to buy into the Medicare program once the extended Medicare coverage is exhausted. Specifically, PL , effective April 1, 1990, provides disabled beneficiaries who are under 65 years of age with the option of purchasing Medicare coverage. They must no longer be entitled to Medicare because of having earnings in excess of the amount and time permitted having exhausted their extended period of Medicare eligibility. Individuals who lost entitlement to Social Security disability benefits due to, and whose Extended Medicare coverage has also terminated, may opt to enroll in premium free Medicare Part A (know as Premium-HI). In order to get Premium HI, individuals must first file an application for Premium-HI, and then a determination regarding medical improvement will be made. Working individuals with disabilities must still meet SSA disability guidelines in order to qualify for Premium HI. See chart on page 58 for Premium HI rates. Note: An individual who has earned at least 30 quarters of coverage will have a reduced rate. Also, individuals who have limited income and resources may qualify for payment by their State. This is known as the Qualified Disability Working Individual provisions (QDWI) and is available through the Medicaid office. Social Security beneficiaries earning over 200 percent of the poverty level are required to pay the full premium; For Social Security beneficiaries earning less than 200 percent of the poverty level, Medicaid is required to pay the entire Medicare premium (in most states). Exercise Questions Use the attached chart to answer the following questions: 1. In what month/year does the TWP begin? end? 2. In what month/year does the EPE being? end? 3. How much of his/her Title II check will the person receive in September 1998? None Half All 4. What month/year would his/her extended medicare coverage cease? 5. What if the person were blind? What would the answers to the above questions be? 2004 Can be reproduced with permission. 65

18 Chapter 6 Benefits Planning, Assistance and Outreach Title II Exercise 1998 Jan Feb March April May June July Aug Sept Oct Nov Dec Countable Earnings Benefit Status 1999 Jan Feb March April May June July Aug Sept Oct Nov Dec Countable Earnings Benefit Status 2000 Jan Feb March April May June July Aug Sept Oct Nov Dec Countable Earnings Benefit Status 2001 Jan Feb March April May June July Aug Sept Oct Nov Dec Countable Income Benefit Status 2002 Jan Feb March April May June July Aug Sept Oct Nov Dec Countable Income Benefit Status 2003 Jan Feb March April May June July Aug Sept Oct Nov Dec Countable Earnings Benefit Status 2004 Jan Feb March April May June July Aug Sept Oct Nov Dec Countable Income Can be reproduced with permission.

19 Benefits Planning, Assistance and Outreach Chapter 6 Flowchart 1: Social Security / TWP An example of how an individual might proceed through the Social Security system Receives Benefits (Title II Medicare) Goes to Work Trial Work Period (9 months within rolling 60 consecutive month period) Receives wages full benefits Starts with first month earnings over allowed limits. $200/40hr. rule $530/80hr. rule $560/80hr. rule $570/80hr. rule Regular Employment Jan 00 $282 Oct 00 $312 Nov 00 $408 Dec 00 $500 Jan 01 $535 Feb 01 $540 Mar 02 $570 Apr 02 $570 Dec 03 $700 Self Employed Jan hrs Oct hrs Nov hrs Dec hrs Jan hrs Feb hrs Mar hrs Apr hrs Dec hrs 2004 = $580 9 months of earnings meeting TWP/income criteria End of TWP In the 10 th month, continuing disability review. Look at. Still medically disabled? Extended Period of Eligibility Extended Medicare Coverage 2004 Can be reproduced with permission. 67

20 Chapter 6 Benefits Planning, Assistance and Outreach Flowchart 2: Extended Period of Eligibility Extended Period of Eligibility (for persons still medically disabled) 36 consecutive months Begins the first month after the 9 th TWP month Receives no cash benefits for months earning over (2004 = $810/$1,350) after the 3 month grace period If work stops or earnings drop below, receive benefits and any earnings. Wages: Benefits Not $500 SS Cessation Month $820 SS $815 SS $880 SS $860 0 $815 0 $820 0 Month: Grace Period 36 months $390 SS $500 SS $600 SS $650 SS $860 0 $820 0 $815 0 $850 0 End of EPE (36 th month of EPE) No Earned Social Security Benefits Continue First month of after EPE benefits discontinued If work cessation is because of disability within 60 months, can file for reinstatement of benefits 2 Pursuant to Conley v. Bowen, 859 F.2d 261 (2d Cir. 1988), this is not true in New York, Connecticut and Vermont, the states within the jurisdiction of the U.S. Court of Appeals for the Second Circuit. Under the Conley holding, SSA cannot terminate benefits unless average monthly wages exceed following the EPE. See Social Security Acquiescence Ruling (AR) 93-2(2), at 3-4; POMS DI et seq Can be reproduced with permission.